Surgical options for recalcitrant carpal tunnel syndrome with perineural fibrosis

Abstract

Surgical release of the transverse carpal ligament for the treatment of carpal tunnel syndrome (CTS) is, in general, a very successful procedure. Some patients, however, fail this standard release and have persistent or recurrent symptoms. Such recalcitrance may relate to incomplete release but more often relates to perineural or intraneural fibrosis of the median nerve. While there is no good treatment for intraneural fibrosis, numerous procedures have evolved in an attempt to treat perineural fibrosis which restricts nerve gliding. These include procedures to isolate the nerve from scar as well as procedures to bring neovascularization to the median nerve. This review describes the various surgical treatment options for recalcitrant CTS as well as their reported outcomes.

Keywords: Carpal tunnel release; Carpal tunnel syndrome; Recalcitrant carpal tunnel syndrome; Revision carpal tunnel.

Fig. 1

a Identification of a superficial vein in the forearm. b The vein has been split longitudinally and the intima portion has been placed against the median nerve. Subsequently, the vein was wrapped around the median nerve multiple times (courtesy of Shriners Hospital for Children, Philadelphia, PA)

Fig. 2

Synthetic device placed around the median nerve (courtesy of Joshua Abzug, MD)

Fig. 3

a Elevation of the hypothenar fat pad. b Placement of the hypothenar fat pad over the median nerve. (Courtesy of Shriners Hospital for Children, Philadelphia, PA)

Fig. 4

a Elevation of the tenosynovial flap utilizing the ulnar aspect as the vascularized pedicle. b Placement of the vascularized tenosynovial flap over the median nerve (courtesy of The Philadelphia Hand Center, Philadelphia, PA)

Fig. 5

a Elevation of the FDS muscle belly without disturbing the myotendinous junction. b Rotation of the vascularized FDS muscle belly 180° to cover the median nerve (courtesy of The Philadelphia Hand Center, Philadelphia, PA)